Recent research shows that approximately 62% of patients with dysthymic disorder will benefit from antidepressant medication. The guidelines for assessing the potential utility of drug therapy are a contributory family history and a past history of poor response to other forms of treatment. The relative ease and efficiency with which such a trial can be undertaken usually outweigh concerns about risks of medications or the appropriateness of their use.
For almost all patients, treatment can take place on an outpatient basis.
Both fluoxetine and imipramine have repeatedly been shown to be effective treatments for this disorder in placebo-controlled randomized double-blind studies. Interesting enough, the response rate to antidepressant therapy is usually in the order of 62%; whereas the response rate to placebo therapy ranges from 19% to 44%.
A number of drugs are not of value for long-term treatment. Those drugs include the amphetamines, the barbiturates, and the benzodiazepines. Those drugs are often prescribed for patients with chronic symptoms of insomnia, fatigue, or tension. However, clinical experience and systematic research indicate that they are little better than a placebo and are at times worse.
Psychotherapy is the principal treatment resource for patients with dysthymic disorder. Reassurance that the clinician understands the depth of the patient's pain, assessment of suicidal and other self-destructive potential, and optimism for the future are all useful.
"Short-term" focused psychotherapy and therapeutic programs that stress changes in interpersonal relationships and cognitive self-awareness are becoming more popular, in part because long-term analytic approaches to personality change are economically unfeasible.
Patients who receive psychotherapy of any of several types - notably cognitive, interpersonally-oriented, or behavior therapy with social skills training - tend to have a good prognosis, with or without antidepressant medication. Analytic and other insight-oriented therapies appear useful for some patients, provided specific neurotic conflict patterns can be elucidated, the patient meets other criteria for this form of treatment, and the clinician is experienced in its use.
No matter what the form of psychotherapy, supportive measures are important. These may range from simple reassurance and education of the patient with respect to the characteristics of his or her illness, to unqualified acceptance of the patient who may at times appear hostile or draining to the therapist, to working with significant others in the patient's life. Successful psychotherapy with the depressed patient usually involves warmth and availability on the part of the psychiatrist, and not the classically "neutral" stance which the patient easily misperceives as uncaring.
Psychotherapy with chronically depressed individuals is an emotionally draining process for the therapist, and recurrent examination of the therapist's own feelings toward the patient is required. Analysis of one's own anger, boredom, or frustration about some aspect of the patient's behavior can help to isolate the key issue in therapy and lead to symptomatic improvement. The patient's unrealistic and idealistic expectations of himself or herself may, for example, be transmitted to the therapist and give rise to overlying optimistic expectations of progress in therapy. If the patient shows no subjective improvement over time, the therapist may inadvertently respond somewhat in the way significant individuals in the patient's life have responded. Interpretation of such personal experiences by the therapist can, in the proper context, be therapeutic.
Although individual psychotherapy is the most common psychosocial treatment offered, many individuals with dysthymic disorder will benefit from group therapy and from active investigation and restructuring of maladaptive social functioning.
Family-centered approaches differ from individual methods in their direct focus on the "role of the sick member" in the family system rather than on the symptoms of the identified patient.
Internet Mental Health (www.mentalhealth.com) copyright © 1995-2011 by Phillip W. Long, M.D.